ImPACT TM Clinical Report

Sample Student
Organization: Subject ID#: Date of Birth: Gender: Handedness: Native country/region: Native language: Years of education completed excluding kinder garden: Received speech therapy: Attended special education classes: Current sport: Primary position/event/class: 7 No No Football Test ID 09/01/1996 Male Right United States Age: Height: Weight: 14 64 inches 111 lbs

Sample Student

Second language: Years Speaking: Repeated one or more years of school: Diagnosed learning disability: Problems with ADD/hyperactivity: No No No

Current level of participation: Junior High Years of experience at this level: 1

Number of times diagnosed with a concussion (excluding current injury): Concussions that resulted in loss of consciousness: Concussions that resulted in confusion: Concussions that resulted in difficulty remembering events that occurred immediately after injury: Concussions that resulted in difficulty remembering events that occurred: Total games missed as a result of all concussions combined: Concussion history:

0 0 0 0 0 0

Treatment for headaches by physician: Treatment for migraine headaches by physician: Treatment for epilepsy/seizures: History of brain surgery:

No Yes No No

History of meningitis: Treatment for substance/alcohol abuse: Treatment for psychiatric condition (depression, anxiety):

No No No

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ImPACT TM Clinical Report

Exam Type Date Tested Last Concussion Exam Language Test Version Composite Scores Memory composite (verbal) Memory composite (visual) Visual motor speed composite Reaction time composite Impulse control composite Total Symptom Score 90 79 29.08 0.55 8 0
80% 69% 33% 93%

Sample Student

Baseline 07/14/2009 English 2.0

Post-Injury 1 08/25/2010 08/23/2010 English 2.0

Post-Injury 2 08/31/2010 08/23/2010 English 2.0

72 55 19.65 0.79 13 31

17% 8% <1% 4%

94 71 33.17 0.59 13 0

88% 39% 34% 56%

Scores in bold RED type exceed the Reliable Change Index (RCI) when compared to the baseline score. However, scores that do not exceed to RCI index may still be clinically significant. Percentile scores if available are listed in small type.

Hours slept last night Medication

10

9.5

The information provided by this report should be viewed as only one source of information regarding an individuals level of [neurocognitive] functioning. Even though impact is based on demonstrated scientific principles and research, external factors such as improper test administration or improper test taking environment may result in inaccurate test results. These factors and others must be considered in making return-to-play decision. The information provided by this report is of a general nature and does not represent medical advice, a diagnosis, or prescription for treatment. Additionally, diagnostic or return to play decisions should not be based solely on the data generated by this report, but on an in-person evaluation made by a professional trained in concussion management in accordance with usual and standard medical practice. An individual suspected of suffering traumatic brain injury or concussion should immediately seek the advice of qualified and trained personnel for interpretation of test results and should be monitored closely for the emergence of symptoms. Impact is not responsible for any decisions based on information contained in the report. A test-takers qualified and trained personnel has the sole responsibility for establishing diagnosis and suggesting appropriate treatment.

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ImPACT TM Clinical Report

Word Memory Hits (Immediate) Correct distractors (immed.) Learning percent correct Hits (delay) Correct distractors (delay) Delayed memory pct. correct Total percent correct Design Memory Hits (Immediate) Correct distractors (immed.) Learning percent correct Hits (delay) Correct distractors (delay) Delayed memory pct. correct Total percent correct X's and O's Total correct (memory) Total correct (interference) Avg. correct RT (interference) Total incorrect (interference) Avg. incorrect RT (interfer.) Symbol Match Total correct (visible) Avg. correct RT (visible) Total correct (hidden) Avg. correct RT (hidden) Color Match Total correct Avg. correct RT Total commissions Avg. commissions RT Three Letters Total sequence correct Total letters correct Pct. of total letters correct Avg. time to first click Avg. counted Avg. counted correctly 4 14 93.33% 2.09 11.2 10.8 3 13 86.67% 3.85 6.8 6.6 5 15 100% 1.74 13.2 13.2 1 0 1 1.34 9 0.93 6 0.86 9 0.84 0 0 27 1.56 7 1.39 27 1.73 5 2.18 27 1.24 8 1.2 8 103 0.58 7 4 78 0.88 7 0.87 7 107 0.51 13 0.41 11 11 92% 10 12 92% 92% 10 9 79% 11 7 75% 77% 11 8 79% 12 9 88% 83.5% 12 12 100% 12 12 100% 100% 8 12 83% 8 8 67% 75% 12 11 96% 10 11 88% 92%

Sample Student

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ImPACT TM Clinical Report

Headache Nausea Vomiting Balance Problems Dizziness Fatigue Trouble falling asleep Sleeping more than usual Sleeping less than usual Drowsiness Sensitivity to light Sensitivity to noise Irritability Sadness Nervousness Feeling more emotional Numbness or tingling Feeling slowed down Feeling mentally foggy Difficulty concentrating Difficulty remembering Visual problems Total Symptom Score 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 2 0 2 0 3 4 0 1 1 2 3 0 0 0 0 0 1 3 3 2 0 31 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Sample Student

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ImPACT TM Clinical Report

Memory Composite (Verbal) 100 80 60 40 20 0
90
07/14/09

Sample Student

Memory Composite (Visual) 100 80 60 40 20

72
08/25/10

94
08/31/10

79
07/14/09

55
08/25/10

71
08/31/10

Visual Motor Composite 60 48 36 24 12 0

29.08
07/14/09

Reaction Time Composite 1.0 0.8 0.6 0.4 0.2

19.65
08/25/10

33.17
08/31/10

0.55
07/14/09

0.79
08/25/10

0.59
08/31/10

Impulse Control Composite 25 20 15 10 5 0

8
07/14/09

Symptom Score 125 100 75 50 25

13
08/25/10

13
08/31/10

0
07/14/09

31
08/25/10

0
08/31/10

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